empirical evidence that psychological aspects of cancer management are important to quality of life, it is perhaps time now to ask why these practices are not being incorporated routinely into cancer treatment. Counselling is now a mandatory part of HIV testing. We should be thinking along the same lines for those people with a prospective diagnosis of cancer. In people with advanced disease the potential for distress is obviously great. It seems, however, that a large proportion of long term survivors pay a high psychological price and continue to have problems many years after treatment has ended.2 Given this, how can the problem be adequately addressed? Where physical health is concerned there can be few dissenters from the belief that prevention is better than cure, yet this principle is rarely extended to psychological health. There are many excuses as to why we should not provide this type of care as routine, ranging from assertions that "everyone will want it" through to claims that "nobody will accept it." To an extent this latter claim acts as self fulfilling: if psychological help is offered in a judgmental and stigmatised way it is no surprise that people are reluctant to accept it. Spiegal et al's group of women with metastatic breast cancer, like the Greer et al cohort, were shown to benefit from therapy.3 Given the groaning weight of evidence, it may be time to stop finding reasons for these aspects of care to fail and take a serious look at some not so new initiatives and how they could potentially prevent the deterioration in quality of life that seems associated with life threatening disease. PATRICIA McHUGH SH6N LEWIS Academic Department of Psychiatry, Charing Cross Hospital, London W6 8RP 1 Greer S, Moorey S, Baruch JDR, Watson M, Robertson BM, Mason A, et al. Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 1992;304: 675-80. (14 March.) 2 Devlen J, Maguire P, Phillips P, Crowther D, Chambers H. Psychological problems associated with diagnosis and treatment of lymphomas. I. Retrospective. BMJ 1987;295:953-7. 3 Spiegal D, Bloom JR, Yalom I. Group support for patients with metastatic cancer. Arch Gen Psychiatry 1981;38:527-33.
Consultants' communications with general practitioners SIR,-How do I write to a general practitioner about a patient's prognosis when it is poor? In the old days a letter to a general practitioner was confidential and I could write honestly. Now it forms a part of records to which the patient has open access, and he or she may well read it. On the same day last week I received two telephone calls from general practitioners. To one I had written a bland letter stating that the patient had received radiotherapy and detailing its possible side effects but omitting any comment about the likely outcome. The general practitioner wanted to know what the prognosis really was so that he could decide how best to plan the patient's care. To the other general practitioner I had written an honest letter about his patient's gloomy prognosis. He thanked me for my honesty but wanted an alternative letter which he could more easily show to the patient. It will be argued that patients should be told about every detail of their condition. Most, however, do not want to know absolutely everything (just as most do not want to know nothing). Telling patients about a life threatening disease is more comfortably done over several consultations, with the picture being filled in gradually. So do I write letters that give an explicit prognosis as soon as this becomes clear or do I give only as much information as I think the patient can accept at a particular time?
1248
Results of investigations may also be seen by the patient. I would not normally disclose the presence of a shadow of dubious importance, a borderline increase in a biochemical variable, or every site of metastatic disease even if I tell the patient that the tumour has spread. It is common for a scan to fail to return to normal after radiotherapy. In the past I would have told the patient that the scan was fine, but now the patient may read that there is residual thickening or slight nodal enlargement. At the very least this requires an explanation about the nature of residual fibrosis or inactive cancer, but many patients will not be reassured without further scanning, a worrying period of waiting, or a biopsy. Perhaps the solution is to telephone the general practitioner if there is something additional that I wish to convey (we do not have to record everything said on the telephone yet). An alternative would be to write two letters, one to the practice and another personally to the general practitioner. In the end I shall probably continue to write bland letters and hope that the general practitioner will read between the lines. GRAHAM READ
Christie Hospital, Mianchester M20 9BX
Freeman Hospital: working to improve services SIR,-Sharon Kingman reports a 7% overall increase in activity at the Freeman Hospital in the current year.' Throughout the election campaign increased activity was used to justify the benefits of the NHS reforms. Yet we need to be very careful in accepting these figures at face value. Contracts are set, and paid for, on the basis of completed consultant episodes (CCEs) and not admissions. If a patient is admitted under one firm and transferred to another firm the next day, one admission generates two CCEs. Because CCEs are the units for quantifying activity, and hence income, they are being much more carefully monitored than previously. Admissions and completed consultant episodes (CCEs) in medicine and surgery in a district general hospital, 1989-90 and 1991-2 1989-90
Admissions CCEs Ratio
Medicine 6 915 8 873 1-28
Admissions CCEs Ratio
12 256 16 323 1-33
1991-2
% Change
7 041 9 768 1-39
1-8 10 1
10 095 14 943 1-46
-17-6 -9-7
Surgery
In my hospital, as a consequence, the ratio of CCEs to admissions has increased over the past two years (table). Thus the apparent 10 1% increase in medical activity corresponds to an extra 1-8% in admissions, and the real decrease of 17-6% in surgical admissions looks less worrying when expressed as a 9-7% decline in CCEs. Is this another example of doctors, as well as the general public, being misled by statistics quoted by managers and politicians?
general practitioners with a twice daily courier service for pathology requests.' Neither this, nor the implication that the hospital currently holds the pathology services contract for the fundholding practice referred to, is in fact the case. It should not be assumed that fundholders and self governing hospitals have an overwhelming natural affinity. The real message is that, whatever the complexion of a hospital's management, the role of the family doctor is central in the new NHS, and any pathology service that fails to recognise this does so at its peril. GORDON DALE
Institute of Pathology, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE I Kingman S. Freeman Hospital: working to improve services. BMJ 1992;304:907-9. (4 April.)
Checking quality of health care records SIR,-Lewis D Ritchie and colleagues claim, by retrospective analysis of computer records, a sustained improvement in primary and preschool immunisation in Grampian during 1990-1.' They conclude that as overall trends were unchanged the 1990 contract for general practitioners has had little effect. But the trend is based on data going back to 1986 (three of five figures in the paper) while the authors refer only to data analysis over the period March 1990 to September 1991. Further, their methods do not describe any quality assurance of the data. We need to know the error in the records and whether it was constant throughout the reported period before considering the authors' conclusions. Errors might occur if children in the target population are never registered; in recording and informing the records system of immunisations and changes in name, address, and general practitioner; and in keying the information. They may be introduced through problems with software and hardware. Sending quarterly reports of nonimmunised children to each clinic is not the same as cross checking with records held by clinics and by parents. Accepting computerised information without checking its quality is absurd. In 1984 Barker et al reported ethnic differences in uptake of immunisation by analysing computerised records on 5637 children with a validation that 50 records had been examined for another study and proved correct.2 We have become more aware of the quality of data,3 and a 1% check on a changing dataset is insufficient. Yet in 1992 we have a report with no check on quality. The measure of quality of health care records is a requirement for research and planning of health care. We suggest that all computer health records need regular standard quality checks. These should be organised in a set way as laboratories use the national external quality assurance scheme.4 It is not just children who need health care and vaccinations: we know that computer records also need checking and protection against their peculiar
viruses. C P J CHARLTON
Queen Elizabeth Hospital for Children, London E2 8PS
C J CUNINGHAME
J S YUDKIN Academic Unit of Diabetes and Endocrinology, Whittington Hospital, London N19 5NF
1 Kingman S. Freeman Hospital: working to improve services. BMJ 1992;304:908-9. (4 April.)
SIR,-In her report on the Freeman Hospital Sharon Kingman gives the impression that it was the first hospital in Newcastle to support local
London N17 7DX I Ritchie LD, Bisset AF, Russell D, Leslie V, Thompson I. Primary and preschool immunisation in Grampian: progress and the 1990 contract. BMJ 1992;304:816-9. (28 March.) 2 Barker MR, Bandaranayake R, Schweiger MS. Differences in rate of uptake of immunisation among ethnic groups. BMJ3 1984;288: 1075-8. 3 Altman DG. Practical statistics for medical research. London: Chapman and Hall, 1991. 4 Audit SteeringCommittee. Guidelinesforaccreditation ofpathology departments. London: Royal College of Pathologists, 1990.
BMJ
VOLUME 304
9 MAY 1992
Consultants' communications with general practitioners SIR,-How do I write to a general practitioner about a patient's prognosis when it is poor? In the old days a letter to a general practitioner was confidential and I could write honestly. Now it forms a part of records to which the patient has open access, and he or she may well read it. On the same day last week I received two telephone calls from general practitioners. To one I had written a bland letter stating that the patient had received radiotherapy and detailing its possible side effects but omitting any comment about the likely outcome. The general practitioner wanted to know what the prognosis really was so that he could decide how best to plan the patient's care. To the other general practitioner I had written an honest letter about his patient's gloomy prognosis. He thanked me for my honesty but wanted an alternative letter which he could more easily show to the patient. It will be argued that patients should be told about every detail of their condition. Most, however, do not want to know absolutely everything (just as most do not want to know nothing). Telling patients about a life threatening disease is more comfortably done over several consultations, with the picture being filled in gradually. So do I write letters that give an explicit prognosis as soon as this becomes clear or do I give only as much information as I think the patient can accept at a particular time?
1248
Results of investigations may also be seen by the patient. I would not normally disclose the presence of a shadow of dubious importance, a borderline increase in a biochemical variable, or every site of metastatic disease even if I tell the patient that the tumour has spread. It is common for a scan to fail to return to normal after radiotherapy. In the past I would have told the patient that the scan was fine, but now the patient may read that there is residual thickening or slight nodal enlargement. At the very least this requires an explanation about the nature of residual fibrosis or inactive cancer, but many patients will not be reassured without further scanning, a worrying period of waiting, or a biopsy. Perhaps the solution is to telephone the general practitioner if there is something additional that I wish to convey (we do not have to record everything said on the telephone yet). An alternative would be to write two letters, one to the practice and another personally to the general practitioner. In the end I shall probably continue to write bland letters and hope that the general practitioner will read between the lines. GRAHAM READ
Christie Hospital, Mianchester M20 9BX
Freeman Hospital: working to improve services SIR,-Sharon Kingman reports a 7% overall increase in activity at the Freeman Hospital in the current year.' Throughout the election campaign increased activity was used to justify the benefits of the NHS reforms. Yet we need to be very careful in accepting these figures at face value. Contracts are set, and paid for, on the basis of completed consultant episodes (CCEs) and not admissions. If a patient is admitted under one firm and transferred to another firm the next day, one admission generates two CCEs. Because CCEs are the units for quantifying activity, and hence income, they are being much more carefully monitored than previously. Admissions and completed consultant episodes (CCEs) in medicine and surgery in a district general hospital, 1989-90 and 1991-2 1989-90
Admissions CCEs Ratio
Medicine 6 915 8 873 1-28
Admissions CCEs Ratio
12 256 16 323 1-33
1991-2
% Change
7 041 9 768 1-39
1-8 10 1
10 095 14 943 1-46
-17-6 -9-7
Surgery
In my hospital, as a consequence, the ratio of CCEs to admissions has increased over the past two years (table). Thus the apparent 10 1% increase in medical activity corresponds to an extra 1-8% in admissions, and the real decrease of 17-6% in surgical admissions looks less worrying when expressed as a 9-7% decline in CCEs. Is this another example of doctors, as well as the general public, being misled by statistics quoted by managers and politicians?
general practitioners with a twice daily courier service for pathology requests.' Neither this, nor the implication that the hospital currently holds the pathology services contract for the fundholding practice referred to, is in fact the case. It should not be assumed that fundholders and self governing hospitals have an overwhelming natural affinity. The real message is that, whatever the complexion of a hospital's management, the role of the family doctor is central in the new NHS, and any pathology service that fails to recognise this does so at its peril. GORDON DALE
Institute of Pathology, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE I Kingman S. Freeman Hospital: working to improve services. BMJ 1992;304:907-9. (4 April.)
Checking quality of health care records SIR,-Lewis D Ritchie and colleagues claim, by retrospective analysis of computer records, a sustained improvement in primary and preschool immunisation in Grampian during 1990-1.' They conclude that as overall trends were unchanged the 1990 contract for general practitioners has had little effect. But the trend is based on data going back to 1986 (three of five figures in the paper) while the authors refer only to data analysis over the period March 1990 to September 1991. Further, their methods do not describe any quality assurance of the data. We need to know the error in the records and whether it was constant throughout the reported period before considering the authors' conclusions. Errors might occur if children in the target population are never registered; in recording and informing the records system of immunisations and changes in name, address, and general practitioner; and in keying the information. They may be introduced through problems with software and hardware. Sending quarterly reports of nonimmunised children to each clinic is not the same as cross checking with records held by clinics and by parents. Accepting computerised information without checking its quality is absurd. In 1984 Barker et al reported ethnic differences in uptake of immunisation by analysing computerised records on 5637 children with a validation that 50 records had been examined for another study and proved correct.2 We have become more aware of the quality of data,3 and a 1% check on a changing dataset is insufficient. Yet in 1992 we have a report with no check on quality. The measure of quality of health care records is a requirement for research and planning of health care. We suggest that all computer health records need regular standard quality checks. These should be organised in a set way as laboratories use the national external quality assurance scheme.4 It is not just children who need health care and vaccinations: we know that computer records also need checking and protection against their peculiar
viruses. C P J CHARLTON
Queen Elizabeth Hospital for Children, London E2 8PS
C J CUNINGHAME
J S YUDKIN Academic Unit of Diabetes and Endocrinology, Whittington Hospital, London N19 5NF
1 Kingman S. Freeman Hospital: working to improve services. BMJ 1992;304:908-9. (4 April.)
SIR,-In her report on the Freeman Hospital Sharon Kingman gives the impression that it was the first hospital in Newcastle to support local
London N17 7DX I Ritchie LD, Bisset AF, Russell D, Leslie V, Thompson I. Primary and preschool immunisation in Grampian: progress and the 1990 contract. BMJ 1992;304:816-9. (28 March.) 2 Barker MR, Bandaranayake R, Schweiger MS. Differences in rate of uptake of immunisation among ethnic groups. BMJ3 1984;288: 1075-8. 3 Altman DG. Practical statistics for medical research. London: Chapman and Hall, 1991. 4 Audit SteeringCommittee. Guidelinesforaccreditation ofpathology departments. London: Royal College of Pathologists, 1990.
BMJ
VOLUME 304
9 MAY 1992
